Transcript Introduction to Pharmacoeconomics

Impact of Under-insurance on
Patients with Breast Cancer
Related Lymphedema
National Congress on the Un and Under Insured
Impact of Being Uninsured or Underinsured Individuals with Cancer
December 11th, 2007
Ya-Chen Tina Shih, Ph.D.
Associate Professor
Section of Health Services Research
Department Biostatistics
Division of Quantitative Sciences
University of Texas MD Anderson Cancer Center
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Breast Cancer Related Lymphedema
(BCRL)

Upper extremity lymphedema (persistent arm
swelling) is one of the most dreaded
sequelae of breast cancer treatment
 BCRL affects 15-30% of breast cancer pts
 Risk factors of BCRL
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–
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–
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Axillary node dissection
Axillary radiation therapy
Mastectomy
High body mass index
Chemotherapy
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Clinical Management of BCRL


No cure for BCRL to date, the mainstay of treatment
is symptom control
Clinical management includes
–
–
–
–
–

Compression therapy
Massage therapy
Use of elastic garment or pneumatic pumps
Manual lymph drainage
…
Complications of BCRL
– Lymphangitis and cellulites
– Other infections

The distressing symptoms of lymphedema has
caused some patients to describe this condition as
“worse than cancer”
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Coverage of BCRL Treatments
Under Women’s Health and Cancer Rights Act
(WHCRA) of 1998, group health plans,
insurance companies and HMOs offering
mastectomy coverage also must provide
coverage for certain services relating to the
mastectomy, including lymphedema
 Not all states passed state laws conforming to
the lymphedema treatment provision of the
WHCRA
 As of Dec 31, 2006, only 21 states required
private insurance to provide coverage for
lymphedema treatment incident to breast
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cancer

State Laws Mandated Private Insurance
to Cover BCRL Treatment in 1998 - 2004
1998
2004
N=1
N=21
Source: NCI, State Cancer Legislative Database
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Study Objective and Hypothesis
Objective: to compare total health care
costs between BCRL patients in states
with versus without coverage mandate
(i.e., the under-insured states)
 Hypothesis: the under-insured states
will incur lower costs in the short run
but higher costs in the long run due to a
higher rate of costly complications

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Data: MarketScan HPM, 1997-2003

MarketScan®: nationwide employment-based
claims data
– Insurance claims from over 100 payers from 45
large employers
– Medical and outpatient prescription drug claims
– Include: employees, spouses, and dependents

Health and Productivity Management (HPM)
– Productivity information (time lost from work) for a
subset of employees
– Include: work loss due to absence, short-term
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disability, or workers’ compensation
Study Sample and Measures

Inclusion:
– lymphedema ICD-9 codes: 457.0; 457.1
– BC-related codes
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•
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Two or more claims on different dates with BC DX
One or more claim indicate BC-related surgery (i.e., mastectomy or lumpectomy)
Two or more claims for non-surgical definitive treatment (i.e., chemo or radiation)
Two or more RX claims for tamoxifen or aromatase inhibitors (AIs)
Exclusion:
– Duration of continuous enrollment < 12 months

Calculation of BCRL-related costs
– Collect all claims for the study sample identified above
– Excluded claims related to BC treatment
•
•
•
•
•
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Surgery: mastectomy, lumpectomy
Radiation
Chemotherapy
Prescriptions of tamoxifen or AIs
Supportive care due to cancer treatment
Tests to determine staging
– Excluded claims related to routine screening and/or testing
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Descriptive Statistics


Age:
mean 49.5 ; SD=8.15
Relationship with employers
– employee
– spouse

(48%)
(52%)
138
200
218
76
2
(21.8%)
(31.5%)
(34.4%)
(12.0%)
(0.3%)
Regions
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–
–
–
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306
328
Northeast
Northcentral
South
West
Unknown
Sample size variations by duration of continuous
enrollment
– One-year
– Two-year
– Three-year
N = 634
N = 447
N = 278
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Comparisons of Total Costs of BCRL
Patients by State Coverage
0 – 12 months
Sample size
Rate of cellulitis or
lymphangitis
Difference
Out-of-pocket pay
Difference
0 – 24 months
Not
covered
Covered
Not
covered
Covered
Not
covered
Covered
504
130
438
92
383
64
11.9%
10.8%
16.2%
8.7%
18.0%
10.9%
P=0.72
Total payment
0 – 18 months
$24,103
$25,147
-$1,044 (P=0.01)
$1,460
$1,521
-$62 (P=0.01)
P=0.07
$32,020
$30,280
$1,740 (P=0.006)
$2,833
$2,195
$638 (P=0.02)
P=0.16
$38,878
$33,164
$5,714 (P=0.031)
$3,279
$2,537
$743 (P=0.03)
Note: Costs in this table include treatment costs related to breast cancer; 2 test was used to compared the rate of cellulitis
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between groups; Mann-Whitney two-sample test was used to compare costs between groups
Cost Comparison by State Coverage
$20,000
$16,000
$12,000
$8,000
$4,000
$0
YR1 covered
Total
YR1 not
covered
RX
YR2 covered
Inpatient
Note: Costs excluded claims possibly related to breast cancer treatment
Outpatient
YR2 not
covered
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Cost Comparison by State Coverage
$16,000
$12,000
$8,000
$4,000
$0
YR1 covered
Total
YR1 not
covered
RX
YR2 covered
Inpatient
Note: Costs excluded claims possibly related to breast cancer treatment
Outpatient
YR2 not
covered
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Cost Comparison by State Coverage
$20,000
$16,000
$12,000
$8,000
$4,000
$0
YR1 covered
Total
YR1 not
covered
RX
YR2 covered
Inpatient
Note: Costs excluded claims possibly related to breast cancer treatment
Outpatient
YR2 not
covered
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Discussion and Conclusion

Compared with BCRL patients in the under-insured
states, those resided in the covered states had
– Similar rate of complication in the first 12 months, but lower rate
in the first 18 and 24 months
– Higher total costs in the first 12 months, but significantly lower
costs in the first 18 and 24 months
– Slightly higher out-of-pocket payment in the first 12 months, but
significantly lower OOP in the first 18 and 24 months
– In year 2: lower total costs, and much lower inpatient costs


Findings confirmed our hypothesis that BCRL patients
resided in the under-insured states incur higher longterm costs from poorly managed lymphedema
Exploratory  need a larger sample size to confirm!!
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Acknowledgement

Funding Source: American Cancer Society
 Collaborators
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HSR/Epidemiology: Linda S. Elting, DrPH
Surgical oncology: Janice N. Cormier, MD, MPH
Breast medical oncology: Sharon H. Giordano, MD
Radiation oncology: Thomas A. Buchholze, MD
Radiation oncology: George Perkins, MD
HSR/Stat analyst: Ying Xu, MD, MS
Nursing, Vanderbilt Univ.: Sheila H. Ridner, PhD, RN
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